A prospective evaluation of hepatic resection for colorectal carcinoma metastases to the liver: Follow-up report

Abstract

Abstract:Single institution studies of hepatic resection have implied that some subsets of patients with metastases from colon and rectum adenocarcinoma can be cured by surgery. However, it is unknown how such patients can be selected and what, in fact, the ultimate cure rate is. The objective of this multi-institutional study was to define in a prospective manner how many patients predicted to have resectable liver metastases actually could undergo curative resection and what the disease-free and overall survival were. A prospec tive 15-institution treatment plan included all patients who were predicted to have resectable metastases from colon and rectum cancer primaries. Results were compared among patients who underwent successful resection, patients who underwent resection with pathologically defined inadequate margins, and patients who underwent exploration but were found at surgery not to have resectable liver metastases. Fourteen institutions throughout North America and one in Milan who were members of the Gastrointestinal Tumor Study Group at the inception of this protocol in July of 1984 participated in the study. The patient population consisted of all those with metachronous or synchronous metastases from colon or rectum adenocarcinoma seen during a consecutive 31 year period with protocol registry at the time liver metastases were predicted to be isolated and resectable. Intervention consisted of the application of standard preoperative screening tests, abdominaI exploration, and resection of all patients who had liver-only surgically resectable disease. The main outcome measures were: Accuracy of preoperative staging, acute and chronic operative morbidity, and disease-free, as well as overall, survival among the three treatment groups. The minimum follow up on all surviving patients after curative resection was 2.2 years, with a median follow up of 3.2 years. Median survival times for patients receiving curative and noncurative resections and for those receiving no resection were estimated to be 35.7, 21.2, and 16.5 months, respectively. No statistically significant difference in the survival distribution of the noncuratively resected Offprint requests to: G. Steele JrReceived for publication on Nov. 15, 1994; accepted on Dec. 7, 1994 or the non-resected patients was observed. The survival distribution of curatively resected patients remains statistically superior to the distribution of noncuratively resected patients and those receiving no resection (P = 0.01). These results confirmed that, although liver resection for hepatic metastases from colorectal car cinoma is safe to do and presently constitutes the only standard curative treatment for potentially resectable disease, it ultimately cures few patients.

Laparoscopy in the management of colorectal cancer metastatic to the liver

“…This partly reflects the accuracy of good quality CT scans in defining intrahepatic lesions and also our aggressive approach to resection, including patients with multiple and bilobar metastases. Overall our resectability rate was 86% (51 of 59 patients) which compares favourably with other units 1,2,7 . We also have employed ablative therapies in conjunction with resection to expand the numbers of patients in whom all intrahepatic disease can be treated 18 .…”

“…In addition, half of the patients deemed incurable with laparoscopy were on the basis of multiple hepatic metastases. The overall resectability rate in this investigation was only 48% whereas other institutions have reported resectability rates of between 79% and 91% 7−9 . Currently the presence of bilobar or multiple metastases are not considered a contraindication to resection 1,2 and the presence of such a low resectability rate in the investigation of Rahusen et al.…”

Major anatomical hepatic resection with regional lymph node dissection for liver metastases from colorectal cancer

“…In many other institutes, patients with positive lymph nodes may be excluded from liver surgery, because of their possible poor prognosis 8,9. It has been reported that all patients with lymph node metastasis died within 3 years after hepatectomy, although it was unclear in those reports whether or not extensive lymph node dissection had been performed 10,11.…”

“…We found that the overall incidence of invasive factors was higher in the recurrent than in the non‐recurrent patients, indicating that recurrence to the remnant liver was closely related to the presence of invasive factors. The rate of remnant liver recurrence after hepatectomy has been widely reported as 74%‐88% 9,15,16. The low remnant liver recurrence rate, 31.3%, in this study thus indicates that major anatomical hepatic resection with lymph node dissection is an appropriate procedure for the complete resection of liver metastases and secondary invasive factors.…”